Enterocolitis and other immunotherapy and targeted therapy-related gastrointestinal manifestations: A review for gastroenterologist.

New oncologic treatments, particularly immunotherapy (IT), have revolutionized the treatment of advanced-stage malignant tumors. Immune checkpoint inhibitors are the main form of IT and act by increasing T cell activity and the organism's immune response against neoplastic cells. Targeted therapy is another form of IT that acts by inhibiting oncogenes or inflammation signaling and tumor angiogenesis pathways. However, these mechanisms of tumor destruction can interfere with the host's immune self-tolerance or with the mechanisms of epithelial tissue repair and predispose to immune system-mediated adverse events that can affect multiple organs, including the digestive tract. The gastrointestinal manifestations of damage caused by IT can range from low-grade mucositis to ulceration, and in some cases, necrosis and perforation. Any part of the gastrointestinal tract can be affected, but there is greater involvement of the small bowel and colon, with a pattern similar to that seen in inflammatory bowel disease. The most common clinical manifestation is chronic diarrhea. The differential diagnosis includes enteropathogenic infections, especially those caused by opportunistic microorganisms; adverse drug reactions; and other inflammatory and malabsorption disorders. Treatment is guided by damage severity. Mild cases can be treated with antidiarrheals and rehydration in the outpatient setting; moderate cases with hospitalization, systemic steroids, and temporary suspension of IT; and severe cases with immunosuppressants or biologic agents and definitive suspension of IT.

Histological transitional zone pull-through in Hirschsprung disease. Postoperative functional results and current recommendations.

BACKGROUND: Surgeons create a neorectum to repair patients with Hirschsprung's disease (HD), which should be formed from a normoganglionic bowel. However, the neorectum is occasionally created with a transition zone (TZ) bowel. A neorectum created with a TZ has been postulated as a cause of postoperative enterocolitis or constipation. This study compares the incidence of enterocolitis and constipation in patients with TZ neorectum and normoganglionic bowel. METHODS: We conducted a retrospective review of patients with rectosigmoid HD who underwent primary pull-through. Patients were divided into normoganglionic neorectum (NNR) and TZ neorectum. The diagnosis was based on the final histopathologic report of the proximal margin. The incidence of enterocolitis and constipation was compared between these two groups. RESULTS: A total of 98 HD patients were analyzed. Seventy-one patients fulfilled the inclusion criteria. 65 (92%) had a NNR, and six patients (8%) had a TZ neorectum. From these patients, 42 (59%) presented with enterocolitis or constipation. However, there was no significant difference between both groups. CONCLUSION: The present study showed no difference in the incidence of enterocolitis or postoperative constipation in HD patients with normoganglionic or TZ neorectum. These results suggest that TZ neorectum does not cause postoperative obstructive symptoms.

INTRODUCCIÓN: Los cirujanos crean un neo-recto para tratar a los pacientes con enfermedad de Hirschsprung (EH), que debe formarse con intestino normogangliónico; sin embargo, en ocasiones el neo-recto se forma con intestino de la zona de transición. Se ha postulado que un neo-recto en zona de transición causa enterocolitis o estreñimiento postoperatorio. El objetivo de este estudio fue comparar la frecuencia de enterocolitis y estreñimiento en pacientes con neo-recto en zona de transición y con neo-recto normogangliónico. MÉTODOS: Se llevó a cabo una revisión retrospectiva de pacientes con EH recto sigmoideo que se sometieron a descenso primario. Los pacientes se dividieron en el grupo neo-recto normogangliónico y el grupo con neo-recto en zona de transición. El diagnóstico del neo-recto se estableció con el informe histopatológico definitivo del margen proximal. Se comparó la frecuencia de enterocolitis y estreñimiento entre estos dos grupos. RESULTADOS: Se analizó un total de 98 pacientes con EH, de los cuales 71 pacientes cumplieron los criterios de inclusión; 65 (92%) con neo-recto normogangliónico y seis (8%) con neo-recto en zona de transición. Posteriormente, 42 (59%) pacientes presentaron enterocolitis asociada a Hirschsprung (HAEC) o estreñimiento; sin embargo, no hubo diferencia significativa entre ambos grupos. CONCLUSIONES: El presente estudio no demostró una diferencia en la frecuencia de HAEC o estreñimiento postoperatorio en pacientes con EH con neo-recto normogangliónico o en zona de transición. Estos resultados sugieren que un neo-recto en zona de transición no causa síntomas obstructivos postoperatorios.

Acidosis metabólica neonatal por síndrome de enterocolitis inducido por proteína de alimentos: reporte de caso / Neonatal metabolic acidosis caused by food proteininduced enterocolitis syndrome: a case report

El síndrome de enterocolitis inducido por proteínas de los alimentos (FPIES, por su sigla en inglés) es una reacción alérgica no mediada por inmunoglobulina E (IgE) con síntomas gastrointestinales, como vómitos y diarrea. El diagnóstico se basa en criterios clínicos y en una prueba de provocación para confirmarlo. Es una enfermedad desconocida en las unidades neonatales, debido a la inespecificidad de los síntomas en los recién nacidos. La cifra de metahemoglobina elevada es una opción sencilla de aproximación diagnóstica. Se describe el caso clínico de un recién nacido que ingresa al servicio de urgencias por deshidratación, letargia, vómitos, diarrea y acidosis metabólica grave con elevación de metahemoglobina, con mejora clínica y recuperación total tras el inicio del aporte de fórmula elemental. La sospecha diagnóstica se confirmó tras la prueba de provocación positiva.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated allergic reaction with gastrointestinal symptoms, such as vomiting and diarrhea. FPIES diagnosis is based on clinical criteria and on a food challenge test. It is an unknown disease in neonatal units due to its nonspecific symptoms in newborn infants. An elevated methemoglobin level is a simple way to approach diagnosis. Here we describe a clinical case of a newborn admitted to the emergency department because of dehydration, lethargy, vomiting, diarrhea, severe metabolic acidosis, and a high methemoglobin level. Clinical improvement and complete recovery was achieved after initiation of elemental formula. The diagnostic suspicion was confirmed after a positive challenge test.

Neonatal metabolic acidosis caused by food proteininduced enterocolitis syndrome: a case report. / Acidosis metabólica neonatal por síndrome de enterocolitis inducido por proteína de alimentos: reporte de caso.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE mediated allergic reaction with gastrointestinal symptoms, such as vomiting and diarrhea. FPIES diagnosis is based on clinical criteria and on a food challenge test. It is an unknown disease in neonatal units due to its nonspecific symptoms in newborn infants. An elevated methemoglobin level is a simple way to approach diagnosis. Here we describe a clinical case of a newborn admitted to the emergency department because of dehydration, lethargy, vomiting, diarrhea, severe metabolic acidosis, and a high methemoglobin level. Clinical improvement and complete recovery was achieved after initiation of elemental formula. The diagnostic suspicion was confirmed after a positive challenge test.

El síndrome de enterocolitis inducido por proteínas de los alimentos (FPIES, por su sigla en inglés) es una reacción alérgica no mediada por inmunoglobulina E (IgE) con síntomas gastrointestinales, como vómitos y diarrea. El diagnóstico se basa en criterios clínicos y en una prueba de provocación para confirmarlo. Es una enfermedad desconocida en las unidades neonatales, debido a la inespecificidad de los síntomas en los recién nacidos. La cifra de metahemoglobina elevada es una opción sencilla de aproximación diagnóstica. Se describe el caso clínico de un recién nacido que ingresa al servicio de urgencias por deshidratación, letargia, vómitos, diarrea y acidosis metabólica grave con elevación de metahemoglobina, con mejora clínica y recuperación total tras el inicio del aporte de fórmula elemental. La sospecha diagnóstica se confirmó tras la prueba de provocación positiva.

[Classification of food allergy: generalities]. / Clasificación de la alergia alimentaria: generalidades.

The prevalence of food allergy has increased in some regions of the world, and with it the incidence, according to geographical variability, in the phenotype and clinical manifestations. Food allergy arises from the specific immune response induced by exposure to the proteins of a certain food. Food intolerance refers to non-immune reactions, caused by unique physiological characteristics of the individual, including metabolic, toxic, pharmacological and undefined mechanisms. Adverse reactions to foods are classified as: IgE-mediated: Type I Hypersensitivity, non-IgE-mediated: Type IV Hypersensitivity, mixed: Types I and IV Hypersensitivity Non-Allergic; toxic, pharmacological, metabolic, intolerances. These types of alterations are rare but have increased in recent years; These include protein-induced enterocolitis syndrome, which can cause emesis, diarrhea and hypotension, and shock, which begins two hours after ingestion of the allergen. Protein-induced allergic proctocolitis is a condition that includes allergy to cow's milk protein. Delayed reactions usually affect the digestive system, are more insidious in their onset and are not immediately controlled, even with the suspension of food. There are eight foods responsible for 90% of food allergies: milk, eggs, soy, wheat, peanuts, walnuts, fish, and shellfish.

La prevalencia de alergia alimentaria se ha incrementado en algunas regiones del mundo, y con ello la incidencia, según la variabilidad geográfica, en el fenotipo y manifestaciones clínicas. La alergia alimentaria surge de la respuesta inmune específica inducida por la exposición a las proteínas de cierto alimento. La intolerancia alimentaria se refiere a reacciones no inmunitarias, causadas por características fisiológicas únicas del individuo, que incluyen mecanismos metabólicos, tóxicos, farmacológicos e indefinidos. Las reacciones adversas a los alimentos se clasifican en: mediada por IgE: Hipersensibilidad Tipo I, no mediada por IgE: Hipersensibilidad Tipo IV, mixtas: Hipersensibilidad Tipos I y IV No Alérgicas; tóxicas, farmacológicas, metabólicas, intolerancias. Este tipo de alteraciones son poco frecuentes, pero se ha incrementado en los últimos años; entre estas se encuentra el síndrome de enterocolitis inducida por proteínas, que puede producir emesis, diarrea e hipotensión, y estado de shock, que inicia dos horas después de la ingestión del alergeno. La proctocolitis alérgica inducida por proteínas es una afectación que incluye la alergia a la proteína de leche de vaca. Las reacciones retardadas suelen afectar el aparato digestivo, son más insidiosas en su inicio y no se controlan inmediatamente, aún con la suspensión del alimento. Existen ocho alimentos responsables del 90% de alergia alimentaria: leche, huevo, soya, trigo, cacahuate, nuez, pescados y mariscos.

[Non-IgE-mediated food allergy]. / Alergia alimentaria no mediada por IgE.

Food allergy is an immune response to proteins in food. It usually affects 8% of children and 2% of adults in Western countries. Non-IgE-mediated food allergy mainly affects the gastrointestinal tract. Gastrointestinal food allergies are classified, by their underlying pathogenesis, as: IgE-mediated, non-IgE-mediated, or mixed. The symptoms of patients with food protein-induced allergic proctocolitis originate from local inflammation of the distal colon, which causes hematochezia in neonates. It can affect the entire gastrointestinal tract and cause symptoms of intractable emesis, with subsequent metabolic disorders and hypovolemic shock. Food protein-induced enterocolitis syndrome is a non-IgE-mediated allergy that usually appears in childhood, with prolonged repetitive vomiting, starting 1 to 4 hours after ingestion of food. The manifestation in adults is usually triggered by the consumption of shellfish. Atopic diseases affect 40-60% of patients with food protein- induced enterocolitis syndrome, including 40-50% of those with food protein-induced enteropathy and proctocolitis. Probiotics (Lactobacillus GG) can alleviate the symptoms of allergic proctocolitis induced by food proteins, by altering the composition of the intestinal microbiota. Fecal microbiota transplantation (FMT) can change intestinal microecology efficiently compared to food or probiotics.

La alergia alimentaria es una respuesta inmunitaria a las proteínas de los alimentos. Suele afectar al 8% de los niños y al 2% de los adultos en países occidentales. La alergia alimentaria no mediada por IgE afecta, principalmente, el aparato gastrointestinal. Las alergias alimentarias gastrointestinales se clasifican, por su patogenia subyacente, en: mediadas por IgE, no mediadas por IgE, o mixtas. Los síntomas de pacientes con proctocolitis alérgica inducida por proteínas alimentarias se originan por la inflamación local del colon distal, que causa hematoquecia en neonatos. Puede afectar todo el conducto gastrointestinal y provocar síntomas de emesis intratable, con subsiguientes trastornos metabólicos y choque hipovolémico. El síndrome de enterocolitis inducida por proteínas alimentarias es una alergia no mediada por IgE que suele aparecer en la infancia, con vómito prolongado repetitivo, que inicia entre 1 a 4 horas después de la ingestión de alimentos. La manifestación en adultos suele desencadenarse por el consumo de mariscos. Las enfermedades atópicas afectan del 40-60% de los pacientes con síndrome de enterocolitis inducida por proteínas alimentarias, incluso al 40-50% de quienes padecen enteropatía y proctocolitis inducidas por proteínas alimentarias. Los probióticos (Lactobacillus GG) pueden aliviar los síntomas de proctocolitis alérgica inducida por proteínas alimentarias, al alterar la composición de la microbiota intestinal. El trasplante de microbiota fecal (TMF) puede cambiar la microecología intestinal de manera eficiente comparada con los alimentos o probióticos.

[Food protein-induced enterocolitis syndrome in a patient with pseudo-Bartter syndrome associated with cystic fibrosis. A case report]. / Enterocolitis inducida por proteínas alimentarias en un paciente con síndrome de pseudo-Bartter asociado a fibrosis quística. Reporte de un caso.

INTRODUCTION: Food protein-induced enterocolitis is a non-immunoglobulin E-mediated food allergy with acute manifestations like recurrent vomiting, dehydration, and shock. It is a rare pathology that requires a high index of suspicion. Pseudo-Bartter syndrome (metabolic alkalosis, hypokalemia and hypochloremia in the absence of tubulopathy) is an infrequent complication of cystic fibrosis. CASE REPORT: A 5-month-old boy with recurrent vomiting, dehydration, and shock; who had been breastfed and had consumed baby formula three hours prior to the onset of symptoms. Laboratory tests confirmed hyponatremia, hypochloremic metabolic alkalosis, and hypokalemia in absence of tubulopathy; two iontophoresis showed altered results, stool elastase was decreased, and genetic sequencing confirmed the diagnosis of cystic fibrosis. The provocation test confirmed food protein-induced enterocolitis syndrome. CONCLUSION: Recurrent vomiting and dehydration after the intake of milk formula must lead to suspicion of food protein-induced enterocolitis syndrome. If pseudo-Bartter syndrome is found, cystic fibrosis must be ruled out.

Introducción: La enterocolitis inducida por proteínas alimentarias es una alergia alimentaria no mediada por inmunoglobulina E, manifestada en forma aguda por vómito recurrente, deshidratación y choque. Es una patología inusual que requiere alto índice de sospecha. El pseudo-Bartter (alcalosis metabólica, hipocaliemia e hipocloremia en ausencia de tubulopatía) es una complicación infrecuente de fibrosis quística. Reporte de caso: Niño de cinco meses de edad con vómito recurrente, deshidratación y choque, alimentado con lactancia materna, pero que consumió fórmula tres horas previas al inicio de síntomas. Los exámenes de laboratorio confirmaron hiponatremia, alcalosis metabólica hipoclorémica e hipocalemia sin tubulopatía; dos iontoforesis mostraron resultados alterados; la elastasa en materia fecal se encontró disminuida y la secuenciación genética confirmó el diagnóstico de fibrosis quística. La prueba de provocación confirmó enterocolitis inducida por proteínas alimentarias. Conclusión: El vómito recurrente y la deshidratación tras la ingesta de fórmula láctea deben hacer sospechar un enterocolitis inducida por proteínas alimentarias. Ante el hallazgo de pseudo-Bartter se debe descartar fibrosis quística.

Recomendaciones para el diagnóstico y el tratamiento de los síntomas posquirúrgicos persistentes en la enfermedad de Hirschsprung / Recommendations for the diagnosis and treatment of persistent postsurgical symptoms in Hirschsprung disease

La enfermedad de Hirschsprung ocurre en 1 de cada 5000 nacimientos. La falla de migración de las células ganglionares desde la cresta neural en dirección cefalocaudal genera su ausencia en parte o todo el colon. Se manifiesta con falta de eliminación de meconio, distensión abdominal y dificultades en la evacuación. Luego del tratamiento quirúrgico, existen complicaciones a corto y largo plazo. El objetivo de esta publicación es describir las principales causas de síntomas persistentes en los pacientes operados por enfermedad de Hirschsprung y presentar un algoritmo diagnóstico-terapéutico factible de ser realizado en nuestro medio

Hirschsprung disease is characterized by the lack of migration of intrinsic parasympathetic ganglia from neural crest and consequently absence of them at varying length of the bowel, resulting in functional obstruction. The incidence is 1 per 5000 births. After surgery, short term and long term comorbidity commonly occurs. The aim of this article is to revise the main causes of ongoing symptoms after surgery in Hirschsprung disease patients and to show a diagnostic and therapeutic algorithm that can be developed in our community

[Food protein-induced enterocolitis syndrome. A case report]. / Síndrome de enterocolitis inducida por proteínas de los alimentos. Reporte de caso.

BACKGROUND: Food protein-induced enterocolitis syndrome or FPIES is a rare, not-IgE-mediated food allergy. The predominant feature is vomit from one to four hours after consuming the causal food. CLINICAL CASE: An 8-month-old boy, with no family history of allergy, with a personal pathological history of allergy to cow's milk protein. At 7 months of age, he had acute gastroenteritis with mixed shock and, at 8 months of age, he had acute gastroenteritis and moderate dehydration. In both episodes, he had eaten rice before the symptoms started. When infectious etiology and other causes of vomit and dehydration were ruled out, the diagnosis of FPIES, which is secondary to rice protein, was made and confirmed with a patch test. CONCLUSION: FPIES should be considered in the differential diagnosis of recurrent gastroenteritis, especially in severe cases without an identified infectious cause.

Antecedentes: El síndrome de enterocolitis inducida por proteínas de los alimentos es una alergia alimentaria poco frecuente no mediada por IgE. El síntoma principal son los vómitos una a cuatro horas después del consumo del alimento causal. Caso clínico: Varón de ocho meses, sin antecedentes heredofamiliares de alergia, con antecedentes personales patológicos de alergia a la proteína de la leche de vaca. A los siete meses había presentado gastroenteritis aguda con choque mixto y a los ocho meses, gastroenteritis aguda y deshidratación moderada; en ambos eventos hubo consumo de arroz previo al inicio de los síntomas. Al descartar etiología infecciosa y otras causas de vómitos y deshidratación, se formuló el diagnóstico de síndrome de enterocolitis inducida por proteínas de los alimentos, secundario a proteína de arroz, que se corroboró con prueba de parche. Conclusión: El síndrome de enterocolitis inducida por proteínas de los alimentos debe ser considerado en el diagnóstico diferencial de gastroenteritis recurrente, principalmente en cuadros graves sin causa infecciosa identificada.

Fatal nosocomial hemorrhagic enterocolitis probably caused by adenovirus. Report of one case.

Adenovirus (ADV) is a recognized cause of severe disease among immunocompromised patients. We report a previously healthy 39-year-old female, admitted with influenza pneumonia and evolving with lung hemorrhage and acute renal failure requiring mechanical ventilation and hemodialysis. She received high corticosteroid doses due to an initial suspicion of alveolar hemorrhage. Lymphopenia already present before steroid use (567/µL), was maintained during the whole hospital stay (mean 782/µL). From the second week of admission she presented a high-volume diarrhea (mean 2.5 L/day) associated to intermittent bloody stools. An ulcerative enterocolitis was confirmed by CT images and colonoscopy. ADV was detected in a colonic tissue sample by real time PCR but not by a commercial filmarray test. Cidofovir-probenecid and racecadotril therapy were indicated without changing the clinical course of diarrhea and the patient finally died.

[Food Protein Induced Enterocolitis Syndrome due to ingestion of kiwi causing potentially severe unexplained event in a child]. / Síndrome de enterocolitis inducida por proteínas alimentarias por ingesta de kiwi como causa de evento potencialmente grave inexplicado en una niña.

Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE food allergy manifesting as profuse, repetitive vomiting, sometimes with diarrhea, leading to dehydration and lethargy that can be severe and lead to shock. Despite the potential severity, awareness of FPIES is low and diagnosis is often delayed, especially in those triggered by solid foods. Presence of vomits and duration of more than 1 minute are the key differential factors to distinguish FPIES from brief resolved unexplained events. We report a case of a 6-month-old infant finally diagnosed as having kiwi induced FPIES.

El síndrome de enterocolitis inducida por proteínas alimentarias es una alergia alimentaria no mediada por inmunoglobulina E que se manifiesta clínicamente con vómitos profusos y repetitivos, en ocasiones, asociados a diarrea, y puede llegar a asociar deshidratación y letargia, con riesgo de desarrollo de shock. A pesar de su potencial gravedad, el índice de sospecha de este síndrome es bajo, lo que demora su diagnóstico, especialmente, en aquellos casos que son desencadenados por alimentos sólidos. La presencia de vómitos y la duración de más de un minuto son los datos clave que pueden diferenciarlo de los episodios breves, resueltos e inexplicados. Se presenta el caso de una lactante de 6 meses de vida con diagnóstico final de síndrome de enterocolitis inducida por proteínas alimentarias por ingesta de kiwi.

Fatal nosocomial hemorrhagic enterocolitis probably caused by adenovirus: report of one case / Enterocolitis hemorrágica fatal nosocomial probablemente causada por adenovirus: informe de un caso

ABSTRACT Adenovirus (ADV) is a recognized cause of severe disease among immunocompromised patients. We report a previously healthy 39-year-old female, admitted with influenza pneumonia and evolving with lung hemorrhage and acute renal failure requiring mechanical ventilation and hemodialysis. She received high corticosteroid doses due to an initial suspicion of alveolar hemorrhage. Lymphopenia already present before steroid use (567/μL), was maintained during the whole hospital stay (mean 782/μL). From the second week of admission she presented a high-volume diarrhea (mean 2.5 L/day) associated to intermittent bloody stools. An ulcerative enterocolitis was confirmed by CT images and colonoscopy. ADV was detected in a colonic tissue sample by real time PCR but not by a commercial filmarray test. Cidofovir-probenecid and racecadotril therapy were indicated without changing the clinical course of diarrhea and the patient finally died.

Adenovirus (ADV) es una causa reconocida de enfermedades graves en pacientes inmunocomprometidos. Informamos el caso de una mujer de 39 años, previamente sana, que ingresó por neumonía grave por influenza, evolucionando con hemorragia pulmonar y falla renal aguda, requiriendo ventilación mecánica y hemodiálisis. Recibió altas dosis de corticoides por la sospecha inicial de una hemorragia alveolar. Tuvo linfopenia durante toda su estadía (promedio 782/μL), la que ya estaba presente antes del uso de los corticoides (567/μL). Desde la segunda semana de hospitalización, presentó una diarrea de alto volumen (promedio 2,5 L/día) asociada a la presencia de sangre en deposiciones en forma intermitente. Se confirmó una enterocolitis ulcerativa por tomografía computada y colonoscopía. Se detectó ADV en muestras de biopsia colónica por PCR en tiempo real pero no por un test de PCR múltiples automatizado comercial. Fue tratada con cidofovir-probenecid y racecadrotrilo sin impacto clínico y la paciente finalmente falleció.

Enterocolitis in a Child With Hirschsprung Disease.

Hirschsprung disease is a congenital abnormality that can be surgically corrected. However, Hirschsprung-associated enterocolitis can be a life-threatening sequela. Very little has been published in the emergency medicine literature about the risk of enterocolitis and shock in patients with a history of Hirschsprung disease. We describe the case of a 6-month-old male infant with a history of multiple surgeries for Hirschsprung disease who presented to the emergency department with a seemingly benign viral gastrointestinal illness. His stable condition led him to be discharged. However, 4 days later, he returned to the emergency department with severe diarrhea and was subsequently admitted to the pediatric intensive care unit for the management of enterocolitis and shock. With this case report, we aim to raise emergency physicians' awareness of the serious and possibly fatal complications of Hirschsprung disease. We argue that this single element of a patient's medical history can alter the management of seemingly simple viral gastrointestinal illnesses; rather than be discharged, such a patient requires surgical consultation and possibly admission for close monitoring and treatment.

Food Protein-Induced Enterocolitis Syndrome Food Challenges: Experience from a Large Referral Center.

BACKGROUND: Food protein-induced enterocolitis syndrome (FPIES) is a non-IgE-mediated food allergy that is diagnosed based on clinical findings, but can be confirmed with oral food challenge (OFC). OFC is more often performed to assess the development of tolerance. Most studies describing OFCs in FPIES are limited in size. OBJECTIVE: We sought to describe our experience with OFCs using our FPIES protocol. Patients were given one-third of serving size with a 4-hour observation period, followed by home titration to full dose. METHODS: We conducted a retrospective chart review of patients who underwent OFC via the FPIES protocol from 2014 to 2017. Data regarding the history of reaction, age at the time of challenge, and reactions during challenge or with home introduction were collected. RESULTS: A total of 169 OFCs were completed under the FPIES protocol, in 119 patients to 19 different foods. Thirty challenges (18%) were positive, with 17 challenges (10%) during initial challenge and 13 (7.7%) during home dosing. Most reactions during initial challenge required intravenous fluids (IVF), but hypotension was uncommon. One hundred thirty-nine (82%) OFCs were negative with home introduction, indicating tolerance to the challenged foods. The mean age of passing a challenge to milk, soy, and grain was earlier than that of other solid foods. CONCLUSIONS: Our data suggest that our FPIES OFC protocol is safe. Early administration of IVF may prevent the development of hypotension. It is difficult to stratify the risk of severe or delayed reaction based on patient characteristics, and more data are needed to identify those appropriate for home introduction.

Food Protein-Induced Enterocolitis Instead of Necrotizing Enterocolitis? A Neonatal Intensive Care Unit Case Series.

Necrotizing enterocolitis is an important disease in infants born premature. However, other disease entities present with similar signs and symptoms. This series reviews 5 atypical cases initially diagnosed as necrotizing enterocolitis that may be more consistent with food protein-induced enterocolitis. Food protein-induced enterocolitis may be underdiagnosed in this population.

Severe forms of food allergy.

OBJECTIVES: To guide the diagnostic and therapeutic management of severe forms of food allergy. DATA SOURCES: Search in the Medline database using the terms "severe food allergy," "anaphylaxis and food allergy," "generalized urticaria and food allergy," and "food protein-induced enterocolitis syndrome" in the last ten years, searching in the title, abstract, or keyword fields. SUMMARY OF DATA: Food allergy can be serious and life-threatening. Milk, eggs, peanuts, nuts, walnuts, wheat, sesame seeds, shrimp, fish, and fruit can precipitate allergic emergencies. The severity of reactions will depend on associated cofactors such as age, drug use at the onset of the reaction, history and persistence of asthma and/or severe allergic rhinitis, history of previous anaphylaxis, exercise, and associated diseases. For generalized urticaria and anaphylaxis, intramuscular epinephrine is the first and fundamental treatment line. For the treatment in acute phase of food-induced enterocolitis syndrome in the emergency setting, prompt hydroelectrolytic replacement, administration of methylprednisolone and ondansetron IV are necessary. It is important to recommend to the patient with food allergy to maintain the exclusion diet, seek specialized follow-up and, in those who have anaphylaxis, to emphasize the need to carry epinephrine. CONCLUSION: Severe food allergy may occur in the form of anaphylaxis and food-protein-induced enterocolitis syndrome, which are increasingly observed in the pediatric emergency room; hence, pediatricians must be alert so they can provide the immediate diagnosis and treatment.

Un caso inusual de síndrome de enterocolitis inducida por proteínas alimentarias / Unusual case of food protein-induced enterocolitis syndrome

El síndrome de enterocolitis inducido por proteínas alimentarias es un síndrome de hipersensibilidad gastrointestinal a alimentos no mediado por inmunoglobulina E, que, en su forma aguda, se manifiesta con vómitos repetitivos, palidez e hipotonía, que puede acompañarse o no de diarrea y producir un cuadro grave de deshidratación y letargia. Una prueba de provocación oral controlada es, en ocasiones, realizada para confirmar el diagnóstico y el tratamiento consiste en la eliminación del alimento causante. Se presenta el caso de un lactante de 3 meses con varios episodios de síndrome de enterocolitis tras la toma de biberón de leche de fórmula de inicio con tolerancia de otra marca comercial. Se encontraron diferencias en los ingredientes de su composición que podrían ser el origen de la sensibilización.

Food protein-induced enterocolitis syndrome is a nonimmunoglobulin E mediated gastrointestinal food hypersensitivity that manifests as profuse, repetitive vomiting, pallor and hypotonia, often with diarrhea leading to severe dehydration and lethargy (sepsis-like symptoms) in the acute setting. An oral food challenge is sometimes performed to confirm the diagnosis and treatment consists of elimination of the food trigger(s) from the diet. We report a case of a 3-months-old infant with several episodes of food protein-induced enterocolitis syndrome after taking infant formula milk with tolerance of another trademark. Differences in the composition of its ingredients could be the cause of the sensitization.

[Unusual case of food protein-induced enterocolitis syndrome]. / Un caso inusual de síndrome de enterocolitis inducida por proteínas alimentarias.

Food protein-induced enterocolitis syndrome is a nonimmunoglobulin E mediated gastrointestinal food hypersensitivity that manifests as profuse, repetitive vomiting, pallor and hypotonia, often with diarrhea leading to severe dehydration and lethargy (sepsis-like symptoms) in the acute setting. An oral food challenge is sometimes performed to confirm the diagnosis and treatment consists of elimination of the food trigger(s) from the diet. We report a case of a 3-monthsold infant with several episodes of food protein-induced enterocolitis syndrome after taking infant formula milk with tolerance of another trademark. Differences in the composition of its ingredients could be the cause of the sensitization.

El síndrome de enterocolitis inducido por proteínas alimentarias es un síndrome de hipersensibilidad gastrointestinal a alimentos no mediado por inmunoglobulina E, que, en su forma aguda, se manifiesta con vómitos repetitivos, palidez e hipotonía, que puede acompañarse o no de diarrea y producir un cuadro grave de deshidratación y letargia. Una prueba de provocación oral controlada es, en ocasiones, realizada para confirmar el diagnóstico y el tratamiento consiste en la eliminación del alimento causante. Se presenta el caso de un lactante de 3 meses con varios episodios de síndrome de enterocolitis tras la toma de biberón de leche de fórmula de inicio con tolerancia de otra marca comercial. Se encontraron diferencias en los ingredientes de su composición que podrían ser el origen de la sensibilización.

Severe forms of food allergy / Formas graves de alergia alimentar

Abstract Objectives: To guide the diagnostic and therapeutic management of severe forms of food allergy. Data sources: Search in the Medline database using the terms "severe food allergy," "anaphylaxis and food allergy," "generalized urticaria and food allergy," and "food protein-induced enterocolitis syndrome" in the last ten years, searching in the title, abstract, or keyword fields. Summary of data: Food allergy can be serious and life-threatening. Milk, eggs, peanuts, nuts, walnuts, wheat, sesame seeds, shrimp, fish, and fruit can precipitate allergic emergencies. The severity of reactions will depend on associated cofactors such as age, drug use at the onset of the reaction, history and persistence of asthma and/or severe allergic rhinitis, history of previous anaphylaxis, exercise, and associated diseases. For generalized urticaria and anaphylaxis, intramuscular epinephrine is the first and fundamental treatment line. For the treatment in acute phase of food-induced enterocolitis syndrome in the emergency setting, prompt hydroelectrolytic replacement, administration of methylprednisolone and ondansetron IV are necessary. It is important to recommend to the patient with food allergy to maintain the exclusion diet, seek specialized follow-up and, in those who have anaphylaxis, to emphasize the need to carry epinephrine. Conclusion: Severe food allergy may occur in the form of anaphylaxis and food-protein-induced enterocolitis syndrome, which are increasingly observed in the pediatric emergency room; hence, pediatricians must be alert so they can provide the immediate diagnosis and treatment.

Resumo Objetivos: Abordar o manejo diagnóstico e terapêutico das formas graves de alergia alimentar. Fontes dos dados: Busca ativa na base de dados Medline dos termos severe food allergies, anaphylaxis and food allergy e food protein-induced enterocolitis nos últimos dez anos e com busca nos campos título, resumo ou palavra-chave. Síntese dos dados: A alergia alimentar pode ser grave e ameaçadora à vida. Leite, ovo, amendoim, castanha, noz, trigo, gergelim, crustáceo, peixe e frutas podem precipitar emergências alérgicas. A gravidade das reações vai depender de fatores associados, tais como idade, uso de medicamentos no início da reação, persistência de asma e/ou rinite alérgica grave, história de prévia anafilaxia, exercício e doenças intercorrentes. Para anafilaxia, a adrenalina intramuscular é uma indicação bem estabelecida. Para o tratamento da síndrome da enterocolite induzida pela proteína alimentar na fase aguda no setor de emergência, fazem-se necessárias a pronta reposição hidroeletrolítica e a administração de metilprednisolona e odansetrona IV. Importante recomendar ao paciente com o diagnóstico de alergia alimentar grave que mantenha a dieta de exclusão, procure acompanhamento especializado e, naqueles que apresentaram anafilaxia, enfatizar a necessidade de portar adrenalina. Conclusão: Alergia alimentar grave pode se manifestar como anafilaxia ou síndrome da enterocolite induzida por proteína alimentar em fase aguda, as quais, por serem condições cada vez mais presentes e reconhecidas no setor de emergência pediátrica, demandam diagnóstico e tratamento imediatos.

Colonic complications following human bone marrow transplantation / Complicações do cólon após transplante de medula óssea humana

BACKGROUND: Human bone marrow transplantation (BMT) becomes an accepted treatment of leukemia, aplastic anemia, immunodeficiency syndromes, and hematologic malignancies. Colorectal surgeons must know how to determine and manage the main colonic complications. OBJECTIVE: To review the clinical features, clinical and pathological staging of graft vs host disease (GVHD), and treatment of patients suffering with colonic complications of human bone marrow transplantation. PATIENTS AND METHODS: We have reviewed the records of all patients that received an allogeneic bone marrow transplant and were evaluated at our Colon and Rectal Surgery department due to gastrointestinal symptoms, between January 2007 and January 2012. The study was carried out in patients who developed colonic complications, all of them with clinical, histopathological or laboratory diagnosis. RESULTS: The study group was constituted by 77 patients, 43 male and 34 female patients. We identified colonic complications in 30 patients (38.9%); five patients developed intestinal toxicity due to pretransplant chemotherapy (6.4%); graft vs. host disease was present in 16 patients (20%); 13 patients (16.8%) developed acute colonic GVHD, and 3 (3.8%) chronic GVHD. Infection was identified in 9 patients (11.6%). CONCLUSIONS: The three principal colonic complications are the chemotherapy toxicity, GVHD, and superinfection; the onset of symptoms could help to suspect the type of complication (0-20 day chemotherapy toxicity, 20 and more GVHD), and infection could appear in any time of transplantation. (AU)

EXPERIÊNCIA: O transplante de medula óssea humana (MOH) passou a ser um tratamento adotado para leucemia, anemia aplástica, síndromes de imunodeficiência e neoplasias hematológicas. Cirurgiões colorretais devem saber como determinar e tratar as principais complicações do cólon. OBJETIVO: Revisar as características clínicas, estadiamentos clínico e patológico da doença do enxerto versus hospedeiro (DEVH) e o tratamento de pacientes padecendo com as complicações colônicas do transplante de medula óssea humana. PACIENTES E MÉTODOS: Revisamos os registros de todos os pacientes que receberam um transplante de medula óssea alogênica e foram avaliados em nosso Departamento de Cirurgia do Cólon e Reto em função de sintomas gastrointestinais, entre janeiro de 2007 e janeiro de 2012. O estudo teve por base os pacientes que desenvolveram complicações do cólon, todos com diagnóstico clínico, histopatológico ou laboratorial. RESULTADOS: O grupo de estudo foi constituído por 77 pacientes, sendo 43 homens e 34 mulheres. Identificamos complicações do cólon em 30 pacientes (38,9%); cinco pacientes exibiam toxicidade intestinal por quimioterapia antes do transplante (6,4%); DEVH estava presente em 16 pacientes (20%), 13 pacientes (16,8%) foram acometidos por DEVH colônica aguda três pacientes (3,8%) DEVH crônica. Infecção foi detectada em 9 pacientes (11,6%). CONCLUSÕES: As três principais complicações do cólon são: toxicidade por quimioterapia, DEVH e superinfecção. O surgimento dos sintomas poderia ajudar a levantar suspeitas sobre o tipo de complicação (0-20 dias, toxicidade por quimioterapia; 20 ou mais dias, DEVH). Infecções podem ocorrer em qualquer momento do transplante. (AU)